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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION i <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FR K D TE ISSIUM <br /> (Complete in Triplicate) <br /> Application in hereby made to Ban Joaquin County for a permit to construct and/or install the vorkherein described. This <br /> APPlication is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules <br /> iJoaquin.County Public Health Services, and Regulations of San <br /> Job Address CityS Lot Size/Acreage &;Vde; <br /> Owner's Name r <br /> tAPhone <br /> Contractor Address /` Z1V t icense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ f SYSTEM REPAIR ) OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca pis. of Well Excavation Dia. of Well Casing f� i <br /> Domestic/Private 0 Gravel Pack ❑ Tracy # Type of Casing_ Specifications <br /> f'l Public 1-1 Other fl Delta s Depth of Grout Seal Type of Grout <br /> — <br /> Repair <br /> I Irrigation. _ -Approx. Depth I I Easiern� ' Surfaica Seal installed by (� <br /> Repair Work pone U r Type of Pumper~ H.P. State Work Done_ Pe t? �\ <br /> Wel! Destruction O Wall Diameter Sealing Material i Depth _1+G111e er.?�f �� � \ <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> w <br /> Installation will serve; Residence available within 200 feat.) <br /> Commercial— Other (� <br /> Number of living units: s N Number of bedrooms �. <br /> Character of WN to a depth`of 3 feet: ° Water table depth <br /> SEPTIC TANK ❑ `Type/Mfg """ Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well #— `� <br /> Foundation Property Lina <br /> LEACHING LINE ❑ 'No. & Length of lines Total length/size <br /> FILTER BED ❑ 'Distance to newest: Well Foundation Property Lina 5 <br /> SEEPAGE PITS I 1 Depth -Siieumberbar <br /> N <br /> SUMPS LI Dists"to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sari Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifin the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workmen's compense-- <br /> tion Uwe of Californle." <br /> The applicant must c II for MI required inspect' s. Complete drawing on reverse side. €f� <br /> Signed TRW n Z, f <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date S— L Area 2— <br /> PR or Grout Inspection by Date Final Inspection by j <br /> Additional Comments: ' <br /> Applicant - Return all copies to: San Joaquin County Public He th Services <br /> Unvironmental Health Permit ervicesr <br /> 445 N San Joaquin, Bo 009, Stkn, CA 95201. <br /> FEE AMOUNT DUE AMOUNT REMI D K <br /> INFO RfCEIV SY DA PERMIT"NO. <br /> EH 1341IAEV.Final D ��y1 t C / � <br /> EH 11•Ie /!r <br />